“The goal of this study was to determine if the rules established by the Centers for Medicare and Medicaid Services (CMS) to determine beneficiaries’ eligibility for medication therapy management (MTM) are appropriate,” says Stuart. “My colleagues and I wanted to gain a better understanding about whether or not these rules were inclusive enough to capture those patients who could gain the most from the interventions associated with MTM.”

Patients who participate in MTM services meet with a pharmacist to review their medication regimen and receive counseling about the importance of taking medications as prescribed. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003, which established the Part D benefit, requires plans to offer MTM services to beneficiaries with multiple chronic conditions, who are taking multiple different medications, and have high annual drug spending.

“Medicare Part D prescription drug plans operate under strict eligibility criteria,” says Stuart. “Prescription drug plans are only required to offer MTM services to those enrollees who have high annual drug spending, a minimum of two or three chronic conditions, and who are taking two to eight different Part D-covered drugs. As a result, only a small percentage of beneficiaries qualify to receive these services.”

Working with F. Ellen Loh, PHSR graduate research assistant at the School of Pharmacy; Pamela Roberto, senior director at Pharmaceutical Research and Manufacturers of America (PhRMA); and Laura M. Miller, senior economist at the National Association of Chain Drug Stores (NACDS), Stuart analyzed data for patients with diabetes, heart failure, or chronic obstructive pulmonary disease who were enrolled in the Medicare Part D prescription drug program. The results showed that poor medication adherence was associated with additional medical and hospital visits, which resulted in additional costs for Medicare Part A and B services in the range of $49 to $840 per beneficiary, per month.

Stuart and his colleagues also produced a new metric – “potentially preventable future costs” – that can be used to target MTM interventions to at-risk beneficiaries with the aim of both improving the quality of care and reducing unnecessary Medicare costs.

“There are a substantial number of Medicare Part D enrollees with low medication adherence whose health outcomes and costs could be improved if they had access to MTM services,” says Stuart. “We suggest that patients’ potential for improved outcomes and decreased health care costs should be added as a criterion when determining their eligibility for MTM services.”

The publishing of the new research follows a significant action by the Congressional Budget Office (CBO) in 2012, which estimated that an increase in the number of prescriptions filled by Medicare beneficiaries reduces spending on other medical services. The CBO will now credit policies that increase use of medicines with savings on other Medicare services.

“We still need a better understanding of the real impact of current MTM interventions,” says Stuart. “Currently, we do not have information about actual MTM interventions and cannot be certain that these services have a major impact on patients’ medication adherence. We hope to address this concern in future studies as new information about these services is released.”

Improper use of and non-adherence to evidence-based medications remain leading causes of poor outcomes and increased health care costs for many Medicare beneficiaries with diabetes, heart failure, and COPD.